Caving in to Costco

The Costco in Long City Island

About ten years ago, they built a Costco in Long Island City, right on the East River and across the street from the Naguchi Museum and adjacent to the Socrates Sculpture Garden. I was aghast at the use of that marvelous space to house a giant box store, and never once considered shopping there.

After all, I am the quintessential New York food snob, one who worships weekly at the cheese counter at Fairway market and whose idea of an orgasmic experience is a good olive. Someone who eschews prepackaged convenience foods as if they were poison, who would rather starve (well, actually, order in) than eat what the rest of America eats. I am not an American, after all. I am a New Yorker. (That’s practically a Parisian.) And I do not shop like Americans do.

At least not until yesterday.

You see, last weekend, at my musical theater class party, I had a piece of one of the most delicious cakes I’ve ever tasted. I was surprised to learn that it was from Costco, as were all the wonderful appetizers. That was interesting, but then I found out what Costco charges for the cakes.

That was it. Like a kid being given their first hit from a schoolyard dealer, all I could think of since then was going to Costco. And yesterday, that’s what Mr. TBTAM and I did.

Mr TBTAM enters Costco

I am still reeling from the experience, which was, in truth, a bit overwhelming in a way that I don’t yet entirely understand. About halfway through the store, at a point when our cart was filled to the brim with paper towels and toilet paper and cases of beer and diet coke, and butter and two giant Nutellas and god knows what else, I just froze.

I was paralyzed and completely overwhelmed. I could buy nothing more. From that point, Mr. TBTAM and I sort of just wandered through the fresh food section, glassy-eyed, until we found our way to the check out counter, where we learned that we should have brought our own shopping bags. We paid with our debit card (they take no plastic except Amex), packed up the car and drove home. I rearranged my pantry to fit everything we bought, and now am sitting trying to understand the experience. Not unexpectedly, I have a few comments and some questions.

1. Does everything have to be so big? I understand if what you are getting is actually large (like the 30 rolls of toilet paper we bought) but why are the SD cards (which in truth are about an inch square) packaged to appear as if they are 20 times that size? The I-Tunes gift certificate package was a full foot square! I don’t understand…

2. Why do you have to pay to shop there? I would have gone long ago if there was not that $50 membership fee. Make the visit free, and you’ll suck in lots more folks like me, I promise…

3. Does one shop there on some regular basis? Or is it just a one time experience, like going to Disney World or Las Vegas? I’m a little worried about going back – I’m afraid of all the money I might spend. Between the membership fee and what we bought, we spent $350 yesterday. I keep telling myself that I saved over $100, but somehow it doesn’t feel that way right now.

4. Does anyone buy the perishables? that’s a rhetorical question – I know they do, because everything looked so fresh. But how do they do it? Does everyone but me have giant freezers? Can you really use that up that many lemons (or oranges, or red peppers) before they go bad? I figured out that for families like the one in Cheaper by the Dozen, this place makes sense. But unless I was having 100 people over for dinner, I don’t know that I can really buy quantities that large for anything perishable.

I could really use some advice here. It occurred to me that I might get together with my neighbors and friends and buy in bulk, then split the stuff up. If anyone does this, maybe you could give me some tips on how to do it smoothly.

5. The prices were so LOW. The shock factor on this was enormous for me. On average, prices were 50% less than what we are paying in the supermarkets. (Example – College Inn Chicken Broth – 50¢ compared with a dollar at the supermarket, and $1.29 at Fresh Direct.) How do they do it? I hope that my price is not ridiculously low because Costco’s employees wages are also ridiculously low. I would certainly be willing to pay another 25% in price if it meant a living wage for these folks. FYI, Most of the workers handing out the food samples did not speak English.

6. They didn’t have my toothpaste. Or my body oil. Or a small enough can of Nina tomatoes for me to ever buy. But I hear the inventory is ever changing – is that really true? If so, is the fact that the inventory changes a factor in keeping us addicted to returning? (Never mind, I just answered my own question.)

7. But they had this really big jar of honey. So, how do I use it? Right from the bottle? Or do I buy something smaller to pour it into? That would be really messy…

8. They do not carry nearly as much variety as Fairway does. Although my wallet was disappointed, I was relieved. I love shopping at Fairway.

9. Is it possible to stop in and buy milk and eggs, and not end up spending $300? I have this idea that we’ll run over once a week, and that once we have all the big bulk items in stock, we won’t be spending as much. Or am I just getting sucked in?

10. I want a big plasma screen TV.

When the Electronic Medical Record Goes Down

Shortly after 10 am on a busy morning not too long ago, our office electronic medical record system went down. It was a system-wide failure, and it lasted for over 12 hours.

Given that we had been online since last June, I was actually pretty impressed when I realized that we had gone as long as we had without a major glitch. But that realization didn’t help much while I was in the midst of busy office hours.

Because, as these things always go, we had done nothing in advance to prepare ourselves for the inevitability of a major EMR down time. Now, of course, we know what to do, and that is the point of this post – to prepare you for the same inevitability in the hopes that you won’t have to go through what we did.

Twelve Steps to Recovery from an EMR Downtime

Step 1 – Admit that you are powerless over the EMR – and that your practice has become unmanageable without it… Oops, sorry. Wrong 12 step program…

Step 1. Don’t panic. There is a back up. If you work in a big place like I do, I can’t imagine you don’t have a mirror server. Have you IT folks prepared to give you read-only access to it while they work on the problem in the background.

Step 2. Be prepared. You would be surprised how quickly all the paper disappears once you’ve been online for a few months. By the time we went down, we had nothing left but a few old lab reqs and blank computer paper. So, long before you ever need it, make a list of paper supplies necessary to function during a prolonged down time. Things like your old visit templates, superbills, radiology and lab requisitions, labels, receipts, message books, etc. Ask input from the entire office staff on this one. Gather a supply of these things (enough for several days if need be) and put it all in a big box or file drawer labeled “EMR Downtime supplies”. Make sure everyone knows where it is, and check it periodically to be sure no one has rifled through it.

And keep a supply of prescription pads locked away in your desk drawer. I had none, and ended up calling in all my scripts that fateful day.

Step 3. Go back to the future. While you are down, shift into paper mode, just like the old days. Write your SOAP notes, check off those boxes in your paper exam template and write your assessment and plan. Write full notes. (Don’t worry – I’ll tell you what to do with those notes in step 9). Don’t count on having the time to recreate it all later – you won’t. I spent an entire Saturday in the office getting back on track because I only wrote little shorthand notes and brief exam summaries, and then had to create the visit note once we were back online.

Step 4. Don’t try to do it all. Patients calling for non-emergent appointments should be asked by your staff (nicely and with profuse apologies) to call back tomorrow. Better yet, have your staff take their number and call them back the next day to schedule. Tell patients needing refills that you’ll get to it tomorrow unless it’s urgent. No point overburdening the staff and you at this moment.

Step 5. Manage the Spin. Make sure your staff notify patients in the office about what’s going on, so they understand if things seem a bit chaotic. No whining and complaining, just cheerful efficiency and mild jokes. Don’t lose track of what’s important – your interaction with the patient. When he/she leaves that day, they should remember that they were the focus, not the office systems.

Step 6. Don’t expect yourself to remember everything. If you can’t get read-only access to your patients’ online records, ask them to fill out a new patient history form in the waiting room before you see them. Since you’ll be running way behind anyway, it’ll give them something to do to feel useful while they’re waiting. I told my patients – “Pretend this is your first visit, and I don’t have your chart – because essentially, I don’t have it. So don’t assume I know everything about your medical history, and tell me anything you think I need to know. You won’t insult me.” No one complained.

Step 7. Don’t compromise patient care. If it’s not an emergency, and you’re uncomfortable starting a new treatment or medication without access to the record, don’t. Tell the patient you’ll review her record once you are back online and call her to finish up the treatment plan at that point. I did this with several patients, and was I glad I did – one woman had forgotten to note in her history form a condition which happened to be a major contraindication to the very treatment option we were discussing. I saw it immediately upon reviewing my records the next day and was able to switch gears with no harm done.

Step 8. Enjoy the down time. Take the time you would have used online checking email or writing consult letters to get to know your office staff. Maybe even order in lunch for everyone. And, since there’s nothing anyone can do once the last patient is seen, you all get to go home early. (That’s the best part…)

Step 9. Plan for an easy catch-up. Next day, when you get back on line, open up your visits from yesterday and write a (very) brief online visit note summarizing any info you’ll need later on to care for the patient. Have your staff scan your paper notes in to the electronic chart as support documentation, and you’re done.

Step 10. Check your charge interface. If you have a direct EMR to billing interface (we don’t – yet), check to be sure that no charges were lost during the down time. Charges from the previous day may have been transferring in at the time of the crash, or been lost during recovery.

Step 11. Learn something from the experience. As soon as possible, meet with your IT team to debrief and plan for the next downtime. Because you all know now that it’s going to occur again. But hopefully, not in the near future.

Step 12. Carry the message. If any of you have gone through a similar experience, and have additional suggestions, do drop a comment below. After all, we’re all in this together.

And, having had a spiritual awakening as the result of these steps, we must try to carry this message to other EMR users, and to practice these principles in all our electronic affairs…

Grand Rounds 3:25

You’ll have trouble deciding what to do when you head on over to Science Roll for this week’s Grand Rounds. There’s lots of great posts, but there are also 4, count ’em, four Monty Python sketches!

My personal faves:Parcho, MD, describes the ideal medicine delivery (one that’s done by anyone other than him), and this Python video shows us the ideal high tech delivery…


Now head on over there and give Science Roll and all the medical bloggers some love.

Night-Clinic in the ER

Grunt Doc is whining about having to deal with patients who present to his ER at night with non-emergent health problems, and I can’t say as I blame him….

I’m just tired of being an emergency physician who works an expensive after-hours clinic. The case that set this off was “I have a toothache for three weeks, and I want to be checked for a discharge I’ve had since my miscarriage”. How long ago was your miscarriage? “5 months”.

Harvard Pilgrim Health Plan may have a solution to your problem, Grunt Doc. Higher deductibles. According to a study in this week’s JAMA:

Traditional health plan members who switched to high-deductible coverage visited the emergency department less frequently than controls, with reductions occurring primarily in repeat visits for conditions that were not classified as high severity, and had decreases in the rate of hospitalizations from the emergency department.

But don’t get too excited yet. Because the higher deductible (HDHP) approach might backfire among the poorer folks.

…reductions in high-severity visits among high-deductible health plan (HDHP)members living in low-income areas …could imply worse outcomes compared with counterparts in traditional plans. Further study is needed regarding long-term utilization patterns in HDHPs, the effect of HDHPs on health outcomes, and effects on low-income populations.

There’s just no simple answer to this one.

But, hey, I’ve got a great idea for a new sitcom. We’ll call it Night Clinic. Wacky patient characters with not so urgent medical problems will have us rolling in the corridors as they annoy the tired ER docs with their crazy antics. Harry Anderson can play the head ER doc. Do you think that really tall guy is free? He’d be great as the triage nurse, or maybe the nightime radiology tech…

Turning Lemons into Lemonade

Gynecology can be a bit of a schizophrenic field. I don’t know of any other area of medicine where the desired clinical outcome can be so completely opposite. I’m speaking of course, about pregnancy. We’re either trying to prevent it, or trying to make it happen, not infrequently in the same patient, just at different times in her life.

One upside to this schizophrenic medicine is that if a treatment worsens one of the outcomes, it may then be good for the other. Take, for example, the Cox-2 inhibitors (Vioxx, Celebrex, Bextra).

COX-2 and the Ovary

Cox-2 is shorthand for cyclo-oxygenase 2, an enzyme that catalyzes the production of prostaglandins from their precursor phospholipids. Prostaglandins are produced in cells all over the body, where they do things like cause smooth muscle to contract, or stimulate pain receptors. They are why you may have menstrual cramps, among other things.

Cox-2 in the prostglandin production pathway

But prostaglandins are not just bad guys – they are thought to have an important role in the physiologic process of ovulation. The ovary has it’s own stores of prostaglandin precursors and cox-2. As ovulation time nears, cox-2 activity in the follicle increases, converting the precursors to prostaglandins. The prostaglandins act to break down the follicle wall and contract the smooth muscle cells in the wall of the ovary, leading to extrusion of the egg. Pretty neat, huh?

Just how important is the Cox-2 enzyme to ovulation? Well, let’s just say that knock-out mice lacking the enzyme are completely infertile. I’d call that important, wouldn’t you?

Cox-2 Inhibitors (The Lemon Part)

Now, as I said before, drugs that interfere with Cox-2 are called Co-x 2 inhibitors. You know them as Bextra, Celebrex and the now defunct Vioxx. You may even have taken them for treatment of menstrual cramps. (For which they are an effective treatment.)

But now that you know what Cox-2 does, you won’t be surprised to find out that taking them can interfere with ovulation. (That’s the lemon part.) In fact, the adverse effect on ovulation is strong enough that it is recommended that women avoid using the Cox-2 inhibitors if they are trying to get pregnant.

A Different Angle (The Lemonade Part)

But, let’s think about it another way, as did the authors of a very interesting study published last month in Human Reproduction.

The investigators took women who were just about to ovulate, and randomized them to receive either the emergency contraceptive pill (ECP) or the ECP + a Cox-2 inhibitor. (Remember that the primary mechanism of action of the ECP is to inhibit ovulation.)

As the graph shows, the addition of the cox 2 inhibitor increased the number of cycles where ovulation was inhibited. This effect was strongest the farther away from ovulation the meds were given, so that the larger the follicle,and the closer to ovulation, the lower the odds were that the treatment would prevent the follicle from rupturing. That’s probably because cox-2 activity is kind of like a runaway train – if you get it early, you can put on the brakes, but if you wait too long, well, let’s just say you’d better step out of the way…

Conclusion? Cox-2 inhibitors are a bad thing if you are trying to get pregnant. But if pregnancy is something you’re trying to avoid right now, they may prove to be quite useful medications.

See? Lemonade.

Make your own Lemonade

The key to great lemonade is to dissolve the sugar by making a syrup. Add some fresh mint to your glass for a special taste.

1 cup of sugar
1 cup of water
Juice of 4-6 lemons (about 1cup)

Pour water into a small sauce pan. Add sugar, and heat, stirring frequently, until the sugar is dissolved completely. Cool a bit. Add the juice and the sugar water to a pitcher. Add around 4 cups of cold water, more or less to the desired strength. Refrigerate 30 to 40 minutes.

Serve with ice and sliced lemons. Serves 6.
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References: Massai MR et al. Human Reproduction 2006; 22: 434-439. / Sirois J et al. Human Reproduction Update 2004 10(5):373-385. (Photos used with permission from Photostock.com. Pathway used with permission from Wickipedia.

Ask a simple question…

Me: Are you sexually active?
Patient A: No.
Me: So, when was the last time you had sex?
Patient A: Last week.
Me: I’m sorry, I thought you said you weren’t sexually active. Should I have asked that differently?
Patient A: You should have just asked me if I have sex.

Me: Do you have sex?
Patient B: Not really.
Me: So you’re not sexually active.
Patient B: No, I am.
Me: And the last time you had sex was…?
Patient B: Yesterday.
Me: I seem to be asking the wrong question…
Patient B: You should just ask me when was the last time I had sex.

Me: When was the last time you had sex?
Patient C (annoyed): How do you know I have sex?
Me: I was just asking…
Patient C: Why not just ask me if I’m sexually active?

The Diet Wars – Atkins wins the first battle

Gardner, CD et al. The A TO Z Weight Loss Study: A Randomized Trial. JAMA. 2007;297:969-977.

Among overweight premenopausal women, weight loss was greater with the Atkins Diet than with the Zone, the Learn or the Ornish diets, according to a study published this week in JAMA. Reassuring was that none of the diets had any major adverse effects on lipids.

But the question we all have that was not answered by this study – How would Atkins fare against South Beach? If you asked me, I would predict a South Beach victory.

On Algorithms and Recipes

I was asked recently to write a treatment algorithm for publication in a specialty throw-away journal. It was harder and took much longer than I expected and in the end, I didn’t like doing it. Because I don’t think I like algorithms.

I hate to think that what we docs do, all that prodding and questioning and examining, the critical thinking and diagnostic accumen, can really be distilled down into a one page diagram with boxes and circles and arrows. There’s just so much more to the practice of medicine than following a pathway.

I was going to say it feels like cookbook medicine, and then I stopped and thought about what the term really means. And I imagined that chefs feel the same way about recipes that I feel about algorithms.

After all, a recipe is just a list of ingredients with instructions on how they are to be combined. It does not tell you how the meat feels when it is done, or how long to beat an egg white so it is stiff without being dry, or how to roll out a pie crust. Those things come with experience, with training and with a love of cooking.

So following a recipe does not make one a great cook, anymore than following an algorithm makes a great doctor.

Lunar Eclipse

I can’t believe no one told me that there was a lunar eclipse last night! I’m so bummed that I missed it. Oh, well – At least it gives me a chance to finally post these pictures I took during the last one…

Photo credits: TBTAM. Canon Power Shot 650 held up to the eyepiece on my telescope. Settings – Auto/noflash (I swear)

Chamomile Tea Squares

Here is my first contribution to Kalyn’s Kitchen Weekend Herb Blogging.

I love chamomile. The plant itself is easy to grow in pots, and has cute little daisy-like flowers that are harvested for tea. It is known for it’s calming properties, and I do find that a cup makes me feel a bit less harried. Chamomile tea straight can be bitter unless it is sweetened or mixed with other teas. I usually drink it unsweetened in a mixture by Tazo called Calm.

I thought that the sweetness of a cookie might be just the right balance for straight chamomile’s bitterness. I modified a classic lemon square recipe, figuring if it worked for the bitter lemon, it would work for chamomile. And it did.

This cookie is actually quite sweet – maybe a bit too sweet for my tastes, though my hubby and kids liked it just fine, thank you. (I’m the one looking for the pucker on my lemon cookies, so you know where my tastes stand.)

Next time, I might use a little less sugar in the filling and I might also use this crust, which is less sweet. I noticed that some lemon square recipes call for baking powder in the filling, and wonder if that would give me a firmer middle without having to bake it so long.

So consider this a work in progress, though not bad for a start.

Chamomile Tea Squares
Vary the strength of the tea depending on how much you like chamomile. Next time I am going much stronger – not everyone could taste that the chamomile. You can really make these with any tea. I want to try Earl Grey next.

Tea
Add one chamomile tea bag to ½ cup boiling water in a pyrex glass measuring cup. (For stronger, use 2 bags and 2 cups of water, steep and then boil it down to 1/4 cup) Let steep. Remove tea bag, pressing against side of cup as you remove it. Discard tea bag. Let tea cool. (You will only be using ¼ cup of this tea, so dilute what’s left over with some hot water and have a cup..).ADDENDUM: neighbors and eldest daughter’s friend could not taste the chamomile, though they loved the cookies. So I recommend making the tea even stronger – Maybe make two cups using 3 bags and then boil it down to 1/4 cup)

Crust:
1 cup all purpose flour
1/2 cup confectioners’ sugar
1/8 tsp salt
4 ounces (1 stick) unsalted butter, cold and cut into 1/2 inch pieces

Filling
2 large eggs
1 cup sugar
2 tbsp all purpose flour
1/8 tsp salt
1/4 cup chamomile tea

Topping
Sifted Confectioner’s sugar

Preheat oven to 350F. Butter and line an 8-inch square pan with parchment paper.

Combine flour, confectioners’ sugar and salt in the bowl of a food processor. Add butter and pulse until the mixture is pebbly. Press evenly into the bottom of your prepared pan. Bake until lightly golden, about 15-20 minutes. Set aside to cool.

Whisk together sugar, flour and salt. Add eggs and whisk until smooth. Whisk in the tea. Pour over crust. Bake until filling is just set, about 2o minutes. Cool completely. Dust with confectioners sugar and cut into squares.

A Blog is Born

My new friend Chris has just started a blog called A View From the Kitchen Window, and it is a joy to read. She is the new Irma Bombeck, and every one of her first three posts had me laughing out loud.

Chris used to have a newpapaper column in Massachusetts, and is clearly a talented writer. If she keeps this up, I predict a book deal within the year. (Well, okay, she still hasn’t gotten the paragraph formatting down in Blogger, but I promised to help her with that very soon…)

In the meantime, head on over there and give her some comments. Every new blogger needs encouragement…

Drop Down Menus – and a Pear Chocolate Tart

Hey, check out my new drop down menus over there in the sidebar. They’re so high tech, so clean, so feng shui. I’m having such a good time making them, and guess what? They’re easy as pie if you have the new version of Blogger. Thanks to Technical Bliss for the how-to’s. And speaking of pie…

Pear Chocolate Tart

Make a pie crust in a tart pan. Let cool. (I used Eggbeater’s pie crust recipe. Thanks Shuna!)

6 oz semisweet chocolate
2 tbsp butter
1/2 cup apricot preserves
1 1/2 oz cognac or brandy
6 pear halves (either canned and drained, or poahced or fresh, soft and ripe as I used today)

Melt chocolate with butter in top of double boiler. Spoon chocolate ontom pie mshell and spread until smooth. Let cool till chocolate hardens.

Melt preserves on low heat. Add cognac and simmer for 3 mins. Strain. (Enjoy the solids yourself!)

Cut pears crosswise into slices. Arrange pieces on tart to from spokes of a wheel. Brush tart with glaze and let sit.

Serve slices with a bit of vanilla ice cream.

Braised Chicken with Tomato, Honey and Saffron

We served this at our dinner party last Saturday, along wth couscous, carrots and a tossed green salad. An easy recipe for a cold winter’s evening. The recipes is adapted from one I found on the website the Global Gourmet, who got it from a cookbook called The Sephardic Kitchen: The Healthy Food and Rich Culture of the Meditteranean Jews. I’ve modified the recipe by adding garlic and wine, cutting back on the fat and using pine nuts instead of almonds.

Chicken Braised with Tomatoes, Honey and Saffron

1-2 tablespoons olive oil
8 chicken thighs and drumsticks (skins off for low fat, on for best flavor) (about 2 lbs)
1 large onion, peeled and finely chopped
2 cloves garlic, chopped
1/2 cup red wine for deglazing
Two 24-ounce cans chopped tomatoes
1/4 teaspoon saffron threads dissolved in 1/4 cup boiling chicken stock
1/3 cup honey
2 sticks cinnamon
1 One-inch piece fresh gingerroot, peeled
1/2 cup toasted pine nuts

1. Heat oil over medium-high heat in a deep, wide sauté pan that has a tight-fitting lid. Brown the chicken on both sides and set aside. If you left the chicken skin on, drain off any excess fat before proceeding to the next step.

2. Sauté the onions in the same pan until translucent. Add the garlic and cook a few minutes more. Reduce the heat and deglaze with 1/2 cup red wine, scraping up browned bits with a wooden spoon.

3. Add the tomatoes and cook until they begin to soften, stirring every once in a while. Add the saffron and honey. Stir well to dissolve. Add the cinnamon sticks and gingerroot.

4. Return the chicken breasts to the pot, making sure they are covered with sauce. Turn the heat down to simmer and cover the pan with foil. Then cover it with its lid. Cook 50 minutes or till done.

5. While the chicken is cooking, toast the pine nuts by cooking them in a dry cast-iron skillet over medium heat or on a cookie sheet in a pre-heated oven at 350 degrees until lightly browned.

6. Remove the chicken to a platter when done and cover to keep warm. If the sauce it too thin, cook it down till it’s where you like it. Remove the cinnamon sticks and gingerroot and pour saurce over the chicken. Sprinkle with pine nuts and serve.